Lack of Older Adults Included in Rheumatoid Arthritis Clinical Trials May Be Hampering Care

Leslie Crofford, MD, professor of medicine and the director of the Division of Rheumatology & Immunology at Vanderbilt University, Nashville, Tennessee, said that clinicians can break down the issues of RA in the geriatric population in several ways. 

First, there may be increased susceptibility to RA with aging as a result of alterations in the immune system. “Immune aging may also increase risk for infections as complications of disease and of treatment. Second, there are age-related comorbidities that may be exacerbated by RA and its treatment. These would include such things as CVD, whose prevalence increases with age, but which is also increased further in patients with RA,” Dr Crofford told Rheumatology Advisor. 

Osteoporosis is also another major concern in this patient population. Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) are much more likely to cause ulcer disease in older patients and their use may be prohibited. “There are little data from clinical trials or other publications that older patients [with RA] respond less well to a given agent than younger people. However, those patients with multiple comorbidities may not be able to receive drugs where the risk outweighs the benefit,” said Dr Crofford. 

Biologic treatments may not be offered to older patients with frequent infections or with a history of cancer because of concerns for adverse effects. For older drugs, such as NSAIDs, prednisone, and methotrexate, higher risks are known, and rheumatologists know to either avoid some medications or reduce the dose in older patients. However, less is known about excess risk with newer biologic agents. 

In theory, some excess risk may be lower for biologics because they do not require metabolism/excretion by the liver and kidneys. Currently, there are no published data suggesting that the biologics infliximab, etanercept, and adalimumab are less safe for those with elderly-onset RA.

Geoffrey J. McColl, MBBS, BMedSc, PhD, associate professor at the Department of Medicine, Royal Melbourne Hospital, Victoria, Australia, published an article in the Journal of Pharmacy Practice and Research stating that those with elderly-onset RA are more likely to have systemic features, such as weight loss, fever, and fatigue. They are also more likely to have large joint involvement.³  The primary goal of treatment for these patients should be to maintain quality of life by eradicating joint inflammation and subsequently reducing joint damage. 

Rheumatologist Elizabeth Solow, MD, instructor of medicine at the University of Texas Southwestern, Dallas, Texas, said several issues arise when caring for older patients with RA.

“Concerns over infection risk, accelerated CVD, drug cost, and medication interactions complicate decision making. Rheumatologists [should] strive to meet patient-centered goals while also balancing disease activity metrics when treating RA,” Dr Solow told Rheumatology Advisor.

She said that early recognition of CVD risk is key. Control of disease activity and coordination with primary care providers for management of comorbid disease may mitigate risk. Biologic DMARDs have been shown to reduce the risk for CVD. 

“However, [these drugs] are expensive and more studies are needed. In our aging population, coordination of care between specialists and primary care will be paramount as well as cost containment of prescription drugs,” said Dr Solow. 

“Patients who [have] RA in their later years face several obstacles, including medication side effects or intolerance, multiple physician visits, and mobility challenges. Care coordination remains the most important challenge for the treating rheumatologist. Guidelines that advocate for patient-centered goals will help guide physicians on what is most important to the patient.”

Disclosures

Dr Marloes van Onna, who commented in this story, has no financial disclosures relating to the subject of these comments. 

Dr Elizabeth Solow, who commented in this story, has no financial disclosures relating to the subject of these comments.

Dr Leslie Crofford, who commented in this story, has no financial disclosures relating to the subject of these comments.